Patient Information Y N Primary Insurance Emergency Contact Information
PATIENT INFORMATION Name (last, first, MI) Address Preferred Phone # OK to leave detailed messages here? Y N Alternate Phone # OK to leave detailed messages here? Y N OK to leave detailed messages here? Y N Email Gender M F Date of Birth T Occupation & Employer Marital/relationship Status Name of spouse/partner Names (& Ages) of Children PRIMARY INSURANCE Primary Insurance Company Name Type of Insurance (please check all that apply): HMO PPO HSA FSA Other For PPO plans (please check all that apply to your specific plan): Out-of-network providers covered High deductible plan Labs covered through LabCorp or Quest (circle one) Berkeley Naturopathic Medical Group is a fee for service clinic. Patients are responsible for payment in full at the time of service. It is each patients responsibility to inquire about insurance reimbursement and to know the limits of coverage in regards to Naturopathic medicine and Naturopathic Doctors. EMERGENCY CONTACT INFORMATION Emergency Contact Relationship to you Preferred Phone # Home Work Cell Alternate Phone # Home Work Cell HOW DID YOU HEAR ABOUT US? How did you find out about the program? If a person, may we thank them for the referral? Yes No 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 510.845.5319 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
CONTEXT OF CARE Why did you choose to sign up for this program? How familiar are you with naturopathic medicine? What three expectations do you have of this program? 1. 2. 3. What expectations do you have of me personally as your doctor/educator? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your diet & lifestyle? (Rate from 0 to 10 with 10 being 100% committed) 1 2 3 4 5 6 7 8 9 10 Do you have any reservations about the 30-day “Flip the Switch” diet that is completed during the program? Do you have any special occasions (eg, birthday, vacation, holiday, etc) that will take place during the course of the program? Have you ever been on a diet in the past? If so, which one(s)? What was your experience? Did you get the results you were looking for? 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 510.845.5319 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
What behaviors/lifestyle habits do you currently engage in regularly that you believe: a. Support your health: b. Are self-destructive: What potential obstacles do you foresee in addressing the diet & lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you? Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making? What do you LOVE to do? WHEEL OF BALANCE Wellness is a balance of many factors. Using the circle below, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Do the same for each area, starting form the center point radiating outwards. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 510.845.5319 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
BLOOD WORK Blood work is an important part of understanding your own unique biochemistry and a helpful way of tracking progress. The following panel of blood work is designed to help us optimize your health as well as screen for some common issues that people experience. This panel may be slightly different than what you might get with your MD because we are looking at it with an eye for prevention. This means we are testing things that conventionally wouldn’t be tested until a specific disease is diagnosed. Blood work is reviewed during week two of the group program and during an initial appointment in the one-on-one program and must be current (within 2 months of the start of the program, please call to discuss if you have had these labs done in the last 6 months). The following fasting blood work is required: o Complete Blood Count with differential o Ferritin o Comprehensive Metabolic Panel 14 o Hemoglobin A1c o Insulin o NMR (a special lipid panel) o Thyroid panel (TSH, free T3, free T4, reverse T3) o Vitamin D, 25-OH o ESR or CRP There are three options for getting your blood work done: o You request that your Primary Care Provider (PCP) order them: Your MD/ND/DO/PA/NP may be willing to order some or all of the necessary blood work. Request that results are copied to Dr Tara Stoop and also directly to you. Bring the results to your initial appointment for the one-on-one program or to the first week of the group program. o You pay for them out of pocket: This is payable to Berkeley Naturopathic Medical Group and the results are released directly to us. Call Berkeley Naturopathic to request a requisition. a. Full panel: 289 b. Full panel with standard lipid panel instead of NMR: 239 c. Limited panel (does not include VAP or thyroid screen): 158 d. Blood sugar panel (only includes fasting glucose, insulin & hemoglobin A1c): 65 o A combination of options #1 and #2: if your PCP is willing to run some but not all of the listed labs, the remaining labs can be paid for out of pocket. It is important that the thyroid panel is run from the same blood draw so it is necessary for your MD to run the entire panel and if not, the entire panel must be done out of pocket. Call Berkeley Naturopathic to request a requisition. Please get your blood drawn after a 10-12 hour fast. No food is allowed but plenty of water is encouraged. Please allow 10 business days for the results to come back so plan to get your blood drawn with adequate time before the start of your program. If you are currently on thyroid medication, please also get the blood drawn 2-4 hrs after taking your morning dose. This allows us to see what your thyroid hormone levels are when the medication is at its peak in the blood. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
Welcome to Wellness & Weight Loss at Berkeley Naturopathic Medical Group! We are happy that you have chosen to pursue Wellness & Weight Loss programs at Berkeley Naturopathic Medical Group. Our goal is to provide you with the highest quality wellness education possible. We are committed to a healthy and honest relationship from the start and for this reason we ask that you take the time to review our program and payment policies. Please sign below to acknowledge that you have read and understand these policies. GROUP PROGRAM: SMALL GROUP FORMAT: Structure: Groups of 3-6 participants 8 lectures (75 min each), once a week (for the most part) Saturday morning lectures at BNMG o Group A: 9:30-10:45a o Group B: 11:00-12:15p o Group C: 12:45-2:00p Fees: One payment . 949 Three payments . . 339 each Blood work is not included in price of program. See separate document on blood work. LARGE GROUP FORMAT: Structure: Groups of 15-25 participants 8 lectures (75 min each), once a week Evening lectures at Energy Matters Acupuncture & Qigong 4341 Piedmont Ave Suite 202 o Mondays 7:00-8:15p (3 of the 8 lectures start at 7:15p) o Thursdays 5:30-6:45p Fees: One payment . 649 Three payments . . 239 each Blood work is not included in price of program. See separate document on blood work. ONE-ON-ONE PROGRAM: Structure Individual and customized discussion of wellness and weight loss goals with structured education at each visit mirroring the group program Call for more info 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
Cancellation Policy: At Berkeley Naturopathic Medical Group, we respect your time, and we trust that you respect ours. For group programs we require a minimum of 8 business days notice* when canceling registration. For one-on-one programs, when canceling or rescheduling appointments, we require a minimum of 3 business days notice* for initial appointments and 2 business days notice* for follow-up appointments. Once registered, whether you choose to pay in full or opt for a payment plan option, if you choose to cancel your enrollment you will be charged the following fees dependent on when you submit your cancelation request: If you cancel before the required cancelation date (as indicated above), you will be charged a 50 cancelation fee. If you cancel after the required cancelation date, you will be charged 50% of the remaining cost of the program. Please understand that this policy is in place as a means of respecting the time and efforts of your doctor/educator and the office staff, as well as others who would have benefited from participation in this program. Should we have to change appointments, we will do our best to give you 2 business days notice and will be sure to accommodate your needs and reschedule your appointment in a timely fashion. *By 5pm on that business day Phone Consultations: If you are unable to come to our office, follow-up visits via telephone are available after an initial in-person visit. These are billed at the regular in-office rate and payment is due via credit card at the end of each call. Email Consultations: Wellness & Weight Loss programs are not offered via email at this time. Confidentiality agreement: The information contained in this program is fundamental and foundational and should be shared with others to improve the health of our communities. Please feel free to verbally share the information you learn in the course and feel free to share copies of the dietary handouts you receive with people you know and care about. Please, however, refrain from sharing the slides from the powerpoint presentations or any recorded material you take or receive during the program. Scent-Free Policy: Our office is a fragrance-free zone. Please refrain from wearing perfume, cologne, and other scented products when visiting us, in order to support the health of our chemically sensitive clients. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
Supplements: All sales on supplements and botanicals are final. Please note that the purpose of selling supplements to patients is to make available the most effective and highest quality products that are often only available for sale through licensed professionals. It may happen that you need a refill prior to your next appointment. Please call or email with your refill request 5 business days before you are scheduled to finish your supplements. Supplement orders requested less than 5 business days in advance will be accommodated as soon as possible but may not be immediate due to available time and stock. All refills must be paid for at the time they are dispensed and can be picked up at the office or mailed to your home. If you need to pick up supplements after hours, supplements are left out at your own risk. Insurance & Payment: Your health insurance policy is a contract between you and your insurance company and you are responsible to know your coverage. Many private insurance companies have policies that do cover some or part of the one-on-one care you receive from Berkeley Naturopathic Medical Group. Whether your particular policy is one that has such coverage is a detail you can learn from your insurance agent as our office does not have access to that information. Group programs are not covered through insurance. All charges incurred at our office are your responsibility regardless of insurance coverage. Payment in full is due at the time of service. This includes fees for medical office visits, labs and any herbal/nutritional supplements prescribed for you. For your convenience we accept cash, check, Visa, and MasterCard. At the end of each one-on-one visit, you will be provided with a superbill that you can use to submit to your insurance for possible reimbursement. The Berkeley Naturopathic Medical Group does not bill insurance and currently, federal programs such as Medicare and Medicaid do not reimburse for naturopathic medical services. Bounced checks incur a 25 processing fee. Refunds on labs are available with a 25 processing fee, provided the labs were not performed, the kits were not tampered with and are returned in a reusable state and that no more than 10 months have passed since their issue. There are no refunds on services. I understand and agree to the conditions listed above. Print Name Signature Date 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
PAYMENT PLAN POLICIES Please take the time to review our payment plan options and policies. Sign below to acknowledge that you have read and understand these policies. Please be aware that blood work is required at the start of the program and is recommended at the end of the program. Any out-of-pocket cost for blood work is not included in price of the program. Please consult the document dedicated to blood work for more information. PAYMENT PLAN OPTIONS: Group program: SMALL: One payment . . 949 each Three payments . . 339 each Group program: LARGE: One payment . . 649 each Three payments . . 239 each PAYMENT METHODS: Credit card (Visa, Mastercard), check and cash payments are accepted. You can also schedule future payment transactions. Make checks payable to Berkeley Naturopathic Medical Group or BNMG By mail: mail to 2615 Ashby Ave. Berkeley, CA 94705 In person: call (510) 845-8600 in advance to make sure a staff member will be present or drop it in the mailbox located on the first floor landing of the stairwell. Over the phone: call (510) 845-8600 to give credit card payment over the phone Your payment plan schedule is as follows: (leave this section blank for staff to complete) PROGRAM: PAYMENT PLAN: Payment #: o Large group o Small group o 1 payment o 3 payments Payment amount: Payment due date: #1 #2 #3 By signing below you are assuming full financial responsibility for the full cost of the course. Registrants will not be permitted to attend the course until full payment or the agreed upon installment has been remitted. Print Name Signature Date 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com
appointment for the one-on-one program or to the first week of the group program. o You pay for them out of pocket: This is payable to Berkeley Naturopathic Medical Group and the results are released directly to us. Call Berkeley Naturopathic to request a requisition. a. Full panel: 289 b. Full panel with standard lipid panel instead of NMR: 239
To activate a patient's Centricity Electronic Medical Record, double-click the patient's name. Double-click Jones, Emma. Creating a Hotlist: Patient Banner . Important: Activate the correct patient's record prior to viewing or documenting patient information. Select patient TAYLOR, Emma. Click the row with TAYLOR, Emma.
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